The first question addressed to Dr Sekar focused on the dual properties of nitric oxide (NO) as being both an antioxidant and a pro-oxidant. In his answer, Dr Sekar discussed the suggestive evidence that lower doses of inhaled NO (iNO) may indeed have more antioxidant properties and that this effect is also influenced by the FiO2 administered to the patient. The second question addressed the problems associated with use of iNO in cases with persistent pulmonary hypertension of the neonate (PPHN) in level III neonatal intensive care units (NICUs) without extracorporeal membrane oxygenation (ECMO) capabilities. The inquiry focused on the difficulties in establishing criteria to determine when patients fail iNO and require transport to an ECMO center. In his answer, Dr Sekar acknowledged that it would be very difficult to establish rigid criteria based on indices of oxygenation status, and in these situations clinical judgment cannot be substituted. Dr Seri added that his group recently published a paper in the Journal of Pediatric Surgery investigating this very topic. Their findings indicate that the dose and duration of iNO administration are predictive for the need of ECMO in neonates with meconium aspiration syndrome and PPHN. However, as these factors are influenced by the protocols of administration and weaning of iNO in a given unit, each unit should develop its own unit-specific predictability model to tackle this difficult question.
The first question addressed to Dr Clyman inquired about the association between spontaneous intestinal perforations (SIPs) and indomethacin administration, especially if the infant was exposed to prenatal steroids. In his answer, Dr Clyman referred to the results of the Trial of Indomethacin Prophylaxis in Preterms (TIPP) trial, indicating that the incidence of SIP or necrotizing enterocolitis (NEC) was unaffected by the use of prophylactic indomethacin in a population with an approximately 80% exposure to prenatal steroids. He stated there is a higher incidence of NEC in the babies who are not exposed to prenatal steroids and have a patent ductus arteriosus (PDA). This finding probably relates to the beneficial effects of antenatal steroids on gastrointestinal maturation.
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